Some thoughts on fall of safety standards - forgetfulness, over-confidence, complacency, arrogance

Anybody or any organization, immediately after an event not to like to happen will have several commitments to itself. I/we will do this or that, now on wards.
Even a student also makes such resolutions in or after an examination, which he did not do better.
But, in most of the cases, nothing will be done.
Some will start, but, the steam is lost.
Very few will sustain to a great extent. Even in such persons/organization will make exemptions, here and there.

This week, I attended a meet organized by a regulator. It was told in the opening remarks that regulators have to do the act of listening, observe the things and make informed decisions. This is applicable even to all those who are in the job of monitoring / advising and they need not be necessarily the designated regulators.

In case of individuals also, we are our own regulators and doers. As a proverb goes, we have one mouth, two ears and two eyes, indicating see and hear more, but talk less.

Coming back to the title, I observed that even in those entities who have developed highest standards, became role models and even are in the business of training, events have taken place for simple reasons which can be avoided / addressed totally before the occurrence of the event. Events in these places make me to think that whether they are wrong in the lessons learnt i.e. whether the lessons learnt for implementation are impracticable.

In many post accident recommendations, training and supervision aspects are listed routinely. Even if the training is good, absorption of the knowledge and its use in the day-to-day affairs is highly doubtful factor. Even those who understood the information too do not implement inspite of knowing that this may lead to incidents.

Like in financial sector, as I read somewhere, risk and returns are proportional. Low risk investments yield less returns and so high risk investments generate huge returns. I had my own experience in share market investment at two different periods and on both occasions, I had the opportunity (!) to learn the lessons to come out with some loss.

I think, it is in human behavior to take risk when it comes our activities, let it be on the roads or work place. And, it is the other way when it comes to our home.

I commute to my work place which is at 13 km from my house, by bike and these thoughts do occur generally, but I am yet to get any reason.

In nuclear field, ALARA (as low as reasonably achievable) concept is preached and is genrally followed to limit radiation dose to occupational workers and public. Whereas in industrial safety, it is ALARP (as low as reasonably practicable) implying that we have to be practicable in taking measures to ensure safety and health of the persons. This also implies (to me) that certain value is attached to human lives for dispensation. If an accident takes place leading to injuries / fatalities, generally we read declaration of compensation. Though enquiry takes place, hardly there are cases where the wrong doers i.e. those responsible for the occurrence of accidents are punished. Every year, lakhs of persons are dying in accidents (on the roads / work place), equal or similar number of persons responsible for these are not punished and it shows that human life got only some number and things will proceed as usual as if nothing happened. Reasons for recurrence are generally as in title of this post. This makes the job of the safety advisers / regulators, a difficult task.

If some disturbance takes place in an inhabited place, police will be blamed for not doing the job. If some emissions take place in a factory, pollution control authorities will be blamed that they are sleeping or accepted something. If some accident takes place, safety adviser will be blamed internally and factory inspectors externally. And so on.
But, little or no action is taken to identify the wrong doers and punish them.

Authorities for control of activities have a difficult task of facing pressures from all around and at the same time, not to succumb to these pressures. They have to be like stones not having any emotions to keep their health and family not to get affected by workplace pressures. Some will resign the post to look for different type of jobs or bade good bye forever (if they are financially resourceful to lead the rest of the life).

Any management would like to have highest productivity at minimal cost. Availability of qualified human resources is an issue face by many. Most of the educational institutions have become factories to churn out the students with good grades / marks but many of them fail miserably in getting suitable employment commensurate with the certificate as they can't answer the questions of the interviewers. Hence, they settle for jobs whatever they can get. They may get satisfied or may not. This can lead to dissatisfaction and doing the job for the sake of earning money only. It requires lot of efforts from the side of managements too train such people and I am not sure how many organizations have the policy of training their manpower before engaging them and then even doubtful case of retraining at regular intervals or change of job / modifications in workplace.

With these things, may be there is some optimal safe production i.e. under present set of conditions, it can deliver X numbers of their products. If we try to stretch production on higher side without commensurate additions / improvements, accidents / failures do take place, if not immediately, but definitely at a later date. This is because, it requires some time, even for the established systems to degrade. Now, if there is a change of management, persons at top can claim for success even at higher production in the beginning (higher production is initially possible because degradation also needs some time), but the person coming later can't deliver the same, because degradation process starts accelerating.

Hence, those with safety in mind have to conclude / decide what is their optimum safe production capacity and stick to it. Else, what we are seeing or reading in papers will continue to happen.

Poor safety management - cause for blasts in chemical factory leading to 23 deaths

The chemical factory stores vinyl chloride (chloroethene, chloroethylene) in three tanks. Two tanks were full with the chemical at the time of the incident. Due to leak, pressure in the tank dropped. Instead of finding the cause for pressure drop, operators pumped more chemical into the tank. This lead to bursting of tank and release of chemical. Ignition source from outside the plant caused explosion of the leaked chemical, burning the trucks and cars outside the plant. 23 persons died and 22 were injured in the incident.

http://www.ecns.cn/news/2018-11-30/detail-ifzahqkf0371003.shtml
http://www.ecns.cn/news/2018-11-29/detail-ifzahqkf0369490.shtml) 
http://www.ecns.cn/news/society/2018-12-10/detail-ifzanuxq9377375.shtml

Boy dies in oven, after entering in it to escape cold weather

A 15 year old boy dies inside the oven, after he enters into it to escape cold weather. The oven door closes leading to the death of the boy.
https://www.indiatoday.in/india/story/up-gonda-teenager-boy-dies-trap-oven-biscuit-factory-1405407-2018-12-08

Similar incident occurred elsewhere. Here, four persons get trapped inside and cooked to death. From the news report, it is understood that they entered again into furnace after their cleaning work is over, did not inform anybody, did not put caution board, did not remove furnace fuse.

https://www.dailymail.co.uk/news/article-2113800/Metalworkers-cooked-death-inside-giant-Austrian-oven-door-closed-800C-furnace-accidentally-switched-on.html

Death from hydrogen gas cylinder blast in IISc Bengaluru

A person was thrown about 20 feet away, hit the wall and died due to suspected hydrogen cylinder blast.  3 others sustained injuries during the incident. 

The window panes and 20 m high roof sheet got damaged.

Small scale hydrogen explosions are made to create shock waves for conducting experiments.

https://www.thehindu.com/news/cities/bangalore/laboratory-accident-at-iisc-kills-one-injures-three/article25671763.ece

https://www.deccanherald.com/city/research-scholar-killed-3-706586.html

Accidents due to opening of the door of cars/trucks

I watched few videos in internet as well as learnt from experiences of friends about fall of persons on the road while walking / driving two wheelers when they were hit by sudden opening of the door of cars/trucks by its inmates.

I feel, it is better to have slide type doors for the vehicles. This type of slide doors shall be made mandatory atleast on the right side of the vehicle where 'drive left' is followed and on left side where 'drive right' is followed. This is, presuming car/truck inmates try to open the door(s), after the vehicle is parked left / right as per the local rules.

Dangerous jobs

https://www.thestreet.com/how-to/most-dangerous-jobs-in-america-14756704

Life as it comes

Last few weeks were hectic. Most part of it, I was on leave, travelling a lot, visiting and staying in the hospital to be with sick relation,  for days together. Within a span of two days, I saw two persons no more while undergoing treatment. Another affectionate old lady whom I met in the hospital earlier, also left this world. To drive final nail, a very close relation and part of my life from childhood, had his last breath who was very active just 20-30 minutes before.

During last two decades, I came across several heart twisting scenes and already made be to think about life and its purpose.

Nothing is in our control. We struggle so much for worldly pleasures, struggle to save the little amounts for facing unknown problems in the future, load the mind with all junk thoughts. But, we are nothing when that moment comes. We do not know where we will be after death. After death, even dead body is not taken inside our own home, people who came to see or our own relations take bath, as if some mud has fallen. The money, property, everything what we thought of as our assets are not ours. We leave this world, with lot of things behind. Those who get possession of these do not give a thought and importance.

In this universe, we are a dust speck and we crave for things. We will be philosophical during emotional breakdowns, only to return to normal self later.

I do not know how one can lead himself to inner peace, but believe that our experiences only will teach us a thing or two in that direction.

Gas leak from air conditioner - three deaths

https://www.thenewsminute.com/article/chennai-family-suffocates-death-due-gas-leak-ac-after-power-cut-89340

Bhilai steel plant - gas pipeline maintenance - explosion - 11 deaths - CEO removed - GM(Safety) & DGM(Energy) suspended

As per reports, 11 persons died due to explosion in Bhilai Steel Plant on 09.11.2018 at about 1030 hr during maintenance of a gas pipeline. 12 persons are undergoing treatment. The explosion took place after removal of bolts of pipeline joint of the gas pipeline. It appears, the line is not depressurized and flushed before opening.

CEO of the plant was removed and two senior officials safety & energy departments were suspended.

https://www.hindustantimes.com/india-news/bhilai-steel-plant-blast-death-toll-rises-to-11-few-others-still-critical/story-4QB4uFAWtJGtwNb0I1d6MI.html

https://indianexpress.com/article/india/explosion-at-chhattisgarh-bhilai-steel-plant-dead-injured-5393509/

https://indianexpress.com/article/india/bhilai-steel-plant-accident-death-toll-rose-to-11-ceo-m-ravi-asked-to-step-away-5395630/

Detergent in aluminum container - hydrogen liberation and explosion

In an incident, a person filled aluminum container with a detergent solution.

http://www.asahi.com/ajw/articles/AJ201810100055.html

This caused hydrogen generation and explosion, causing burn injuries to two persons.

As per theory, alkalis can react with aluminum leading to hydrogen gas generation.

http://www2.uni-siegen.de/~pci/versuche/english/v44-10.html

Toxic drug with potential to harm many was seized

Fentanyl drug used to treat pain of cancer patients. 

https://medlineplus.gov/druginfo/meds/a605043.html

9 kg of the drug was seized.

https://timesofindia.indiatimes.com/india/doomsday-chemical-seized-us-hating-scholar-arrested/articleshow/66011402.cms

Need for controlling residential growth around industrial area

https://www.deccanherald.com/city/graphite-india-factory-too-693590.html

Developing thick skin

https://www.forbes.com/sites/alizalicht/2017/05/04/7-ways-to-develop-a-thick-skin-in-the-office/

Construction labour falls down - 3 rods enter the body - person suffers injuries

Doctors had tough time to save the injured with 3 rods in his body.

https://timesofindia.indiatimes.com/city/kolkata/doctors-couldnt-carry-out-tests-because-of-protruding-rods/articleshow/65331052.cms

Fall of fumigation bottle in hospital releases toxic gas

In an incident of fall of a bottle containing fumigant, toxic gas is released in the hospital. Contact of fumigation chemical with water was believed to cause release of toxic gas.

Some fumigants upon inhalation can cause several health effects like nausea, headache, chest pain, drowsiness, etc.

Phosphine is one of the fumigation gas used for the purpose.



http://www.dnaindia.com/jaipur/report-gas-leak-at-mathuradas-mathur-hospital-in-jodhpur-kid-dead-icu-evacuated-2644137

Entry in to boiler for maintenance - 3 deaths

Three persons lost their lives inside a boiler while attending maintenance. For entry into confined spaces (a space which is not a regular work place), the area needs monitoring before entry for ensuring safe work atmosphere. The oxygen levels and presence of other pollutants will be checked, the area will be flushed with air before and during work to ensure that the work area is as good as working in open atmosphere anywhere.


http://www.newindianexpress.com/cities/bengaluru/2018/jul/12/bengaluru-toxic-gas-snuffs-out-three-lives-inside-boiler-at-anthem-biosciences-factory-1842047.html

Property damage from septic tank explosion

Septic tank explosions are possible and are dangerous. This particular explosion appears to have been heard by persons even kilometers away. Normally, methane, hydrogen sulfide and other gases like carbon dioxide are generated from these tanks.

https://globalnews.ca/video/3882959/septic-tank-explosion-in-china-kills-at-least-19-destroys-neighbourhood

https://forum.susana.org/human-tragedies-examples/21967-septic-tank-explosion-an-explosion-that-ripped-through-the-chinese-megaport-of-ningbo

Job / work related stress - injuries

A good article (in a blog) on injuries from work related stress is available in the link below.

https://blogs.lawyers.com/attorney/workers-compensation/stress-and-workplace-injuries-49091/

Stress results in burnout quickly and performance can be affected. Further to this, one is prone to accidents from lack of concentration / clarity due to so many thoughts lingering in mind to meet the demands.

Road accident data for Jan-Mar 2018 in Maharashtra

About 100 road accidents are taking place everyday in the state and about 30 persons lost their lives everyday. 

The news report is available here.

http://www.freepressjournal.in/mumbai/12264-people-died-in-35853-road-accidents-in-maharashtra-in-2017/1317931

Person driving 2-wheeler with cellphone talking

See the incident in the following link that appeared in yahoo news.

https://in.news.yahoo.com/caught-cam-cell-phone-driving-012500011.html

Death during filling of balloons with helium gas

During the filling of balloons with helium gas from a cylinder, suddenly it exploded. Due to the impact of explosion, the boy aged 17 years died on the spot.

https://timesofindia.indiatimes.com/city/trichy/boy-dead-in-helium-cylinder-explosion/articleshow/64240137.cms

Under construction bridge / flyover collapse in Varanasi on 15.05.2018 - reasons

As per reports, the bridge / flyover collapse leading to 18 deaths was due to issues involving design, quality, barrication, supervision. Proper records and checklist were not maintained making it difficult to ascertain the material used for concreting.  Pour card filling is to be done so that all details like area of work, ratio of cement, sand, water used, status of shuttering etc will be noted and signed by all concerned.

https://www.firstpost.com/india/varanasi-flyover-collapse-initial-probe-identifies-6-lapses-in-construction-advises-strict-action-against-high-ranking-officials-4474481.html

At least 8 students, 1 teacher injured in chemical fire at Hendersonville school

At least 8 students, 1 teacher injured in chemical fire at Hendersonville school: An official with the Hendersonville Fire Department said 17 students and one teacher were either triaged at the scene or transported to local hospitals.

During an experiment in lab by students to see change of flame colours of different salts, the incident happened. The incident appears to have happened to demonstrate rainbow flame by adding different salts to ignited ethyl alcohol. A flash fire occurred lasting 3-5 seconds.

In laboratories, will be working with known/unknown materials. The awareness on lab safety particularly in schools/colleges is generally low compared to industrial safety. Knowledge on properties of chemicals, methods to avoid hazards, control and mitigation measures, use of personal protective equipment, etc will help in avoid consequences from the work. Making safety principles as a topic in every subject let it be science / engineering / arts can help improving awareness.


https://www.washingtonpost.com/news/education/wp/2018/05/09/a-classroom-science-experiment-turned-into-a-chemical-fire-injuring-17/?noredirect=on&utm_term=.f3e0c55beb7f


http://www.wsmv.com/story/38149598/principal-8-students-1-teacher-injured-in-fire-at-hendersonville-school

https://www.washingtonpost.com/local/education/high-school-chemistry-lab-fire-prompts-warnings-for-science-teachers/2015/11/05/eb78543e-8312-11e5-9afb-0c971f713d0c_story.html?utm_term=.4025ee47ffa1

http://www.wkrn.com/top-news/chemistry-safety-experts-warn-schools-to-stop-unsafe-science-demonstrations/1172474948

Ammonia causes chemical burns

During unloading, ammonium hydroxide from the tank splashes on the face of the person causing chemical burns. The person was taken to hospital for treatment.

https://www.wday.com/news/accidents/4434335-man-airlifted-fargo-serious-chemical-burn

Fire and explosion in pharma factory

In an incident of explosions in pharmaceutical factories that stored combustible chemicals, one person died, few persons suffered burn injuries, 3 of them serious. As per the reports, it is not clear whether it is boiler explosion or chemical reactor explosion.  Blast could be felt 12 km from the factory site. Window panes of buildings at 3 km were shattered.

https://timesofindia.indiatimes.com/city/mumbai/four-injured-in-explosions-at-tarapur-midc-units/articleshow/63225257.cms

http://indianexpress.com/article/india/maharashtra-blast-fire-in-chemical-unit-in-palghar-5091363/

https://www.youtube.com/watch?v=ZNJ-w6eEI3k


Additional info.: 3 persons die in the accident

http://indianexpress.com/article/cities/city-others/three-die-in-tarapur-industrial-unit-set-up-in-1978-tarapur-midc-has-an-infamous-history-of-accidents-5092536/

One will be surprised with statements in the report!!!